ICS 2013

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Transcript of ICS 2013

So What is Delirium?And why should I care??!!?Different QuestionsWhat was keeping patients in my ICUIntroductionTransition to translationWhy is this important?Doesn't everyone "pump brain"Bedside to the BenchHow can we answer this clinical conundrumWhere do we go from here?What are the opportunities to interveneA work in progressEnsuring that patient not only survive but THRIVE after cardiac surgeryMy Career So FarUniversity of Toronto Medical School"Maybe I'll just do ICU""I'm Going to be Rehabilitation SpecialistStarted my clerkshipDalhousie UniversitySummer research project at Lyndhurst HospitalDr. Robert MaggisanoResearch - "Yuck""I'm going to do a Critical Care Medicine Fellowship""I need a job!"66% percent of patents have at least mild cognitive dysfunctionDetermining the Impact of Frailty on Cardiac Surgery PatientsBELLOMO, R. (2011). RECENT ADVANCES IN CRITICAL CARE MEDICINE RELEVANT TO CARDIAC SURGERY. HEART, LUNG & CIRCULATION, 20(3), 170–172.The delivery of high-quality critical care medicine is vital to the success of cardiac surgeryThe Cardiac Critical Care Perspective PerspectiveDeliriumStatement of the ProblemWho is at risk following Cardiac Surgery? Effectiveness of a systematic screening program

Impact of Depression following Cardiac SurgeryOutlineJessup et al., N Engl J Med 2003;348:2007-18.Heart failure (HF) affects over 350,000 CanadiansThe medial survival after the onset of HF is 2 years in men and about 3 year in women, and worsens with advancing age One-year mortality: 25% - 40%

Ho KK et al. Survival after the onset of congestive heart failure in Framingham Heart Study subjects. Circulation 1993;88: 107–15.Canadian EpidemicWhat are the issues that impact the the postoperative cardiac surgery patient?What is unique about the CVICU?No Financial DisclosuresBut willing to entertain anyWhat is delirium to a patient?Dementia is chronic and slowly progressivea primary brain disease

Delirium is acute and rapidly progressivethe effect of systemic illness (sepsis, metabolic disturbance, medication toxicity, ACS, hypoxia) on a VULNERABLE BRAIN.It is not DEMENTIADelirium is an acute confusional state characterized by fluctuating mental status, inattention, and either disorganized thinking or altered level of consciousness.DefinitionWhat does delirium look like?Current PathThe Path of a Patient Through Cardiac SurgeryPatient is referred toa CardiologistH+P (Cardiac risk factors)TestingDetermine if a surgical lesion existsRefer to a cardiac surgeonSurgical ConsultationPatient is examined and medical chart/testing reviewed

Surgeon does the "eye ball" test

Determines risk of operative mortality

Consents patient for surgeryNow the wait beginsWait around in fearThe miracle happensExposed to intraoperative "insult"Back to the EthosPrimary CareRate of Cardiac Surgery1:1000 populationICCS12-24 hours of potential hemodynamic instabiltyStandard Clinical Diagnosis

Based on STS’ definition of delirium: “a mental disturbance marked by illness, confusion, cerebral excitement and having a comparatively short course”.12Delirium AssessmentHigher Mortality

Longer Hospital Length of Stay

Higher Chance of Disposition to Assisted Living Facility

Higher Probability of Developing Dementia at 48 months63% vs. 8%Why?It is important to exclude any medical conditions that may be causing the delirium.

“Delirium should be considered a medical emergency”CAM+13Delirium AssessmentThe CONFUSION ASSESSMENT METHOD

Validated, standardized evidence-based tool

Designed for use by bedside clinicians

Takes less than 2 min to complete

Requires minimal trainingDoes the Environment Matter?10STUDY DESIGN:

A retrospective analysis of consecutive patientsundergoing cardiac surgery during two time periods at a single hospital.

Study how implementing a systematic screening program could influence the identification of delirium after cardiac surgery.

To identify independent perioperative risk factors associated with delirium after cardiac surgery in a cardiac population assessed by systematic screening.ObjectivesDrugs that produce delirium are not benign Conscious = arousal and brain contentDrugs may be neurotoxic

Ely EW et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA (2004) 291:1753-1762.ICU Delirium Increases MortalitySource of distress for both family and patient

Gottesman RF et al, Ann Neurol 2010;67:338–344Delirium in Cardiac SurgeryPost-operative delirium is very difficult to manage once it has occurred. ? efficacy strategies that have been publishedWhy is it a problem?

The prevalence of delirium after cardiac surgery is very variable ranging from 3-73%

Criteria for an indicator of the quality of health care: commonfrequently iatrogenicintegrally linked to processes of care? PreventableIs there an interaction with postoperative delirium and depression?

What is the impact at 1+ yearsseeking help for mental illness/new MDEnew pharma Rxsucidical ideationloss of productivity/loss of employmentcognitive effectsQuestions that remain3rd Annual Meeting

American Delirium Society Omni Hotel and Conference Center Indianapolis, Indiana June 2-4, 2013American Delirium SocietyTHANK YOUYou can fool some of the people all the time, and those are the ones you want to concentrate on. - George W. BushThe Duhamel ExperienceAcknowledgementsMRP-CORE InvestigatorsClaudio Rigatto, Navdeep Tangri, Paul Komenda, Manish SoodAcknowledgementsFunding SourcesMHRC, MMSF, U of M, Cardiac Sciences ProgramAcknowledgementsHilary Grocott